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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> PLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. &_ 5 5_3 <br /> q 573 <br /> THIS PERMIT EXPIRES, 1 YEAR FROM DATE ISSUED Date Issued 3--7 2-- <br /> (Complete <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION lIq CENSUS TRACT <br /> Owner's Name Q 4,o ���c_ 4�,r t�� Phone <br /> Address ( 1914 pct ��� <br /> � �`�u � L�� S�� . �c.l`..__- __- = — _ city � <br /> Contractor's Name ��,! _}�� �Cryt�, License ��`���}�S(Phone <br /> TYPE OF WORK (Check) : NEW WELL DEEPEN '/-7 RECONDITION / / DESTRUCTION /_7 <br /> PUMP INST LATION PUMP REPAIR/ / PUMP REPLACEMENT /_7 <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESQ aZ PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .9 <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing 14 ` <br /> Domestic/public Driven Gauge of Casing 0- �a Z <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout G, O <br /> Other Other Information <br /> PUMP INSTALLATION: Contractor 4 ��`G/ cr <br /> Type of Pump � H.P. <br /> PUMP REPLACEMENT: / / State Work Done �? <br /> PUMP REPAIR: / / State Work Done <br /> .DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joa�&n Local Health District <br /> and the State of California pertaining to or regulating well. construot,ion. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> IL <br /> WEL RLERS REPORT of the well and notify them before putting the saell .in use. The above <br /> 2fform t' n is true the est of my kn ledge and belief. <br /> SIGNS TITLE' <br /> D PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY M _ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE 11 GROUT INSPECTION = PHA4E III tINAL INSPECJTON r <br /> INSPECTION BY DATE I9SP_ECTION B `' DATE ' <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION'. <br /> E H 1426 4/72 1M <br /> r ;.,r <br />